Provider Demographics
NPI:1821147646
Name:DEJONGE, KATHRYN MULDER (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:MULDER
Last Name:DEJONGE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KATHRYN
Other - Middle Name:LYNN
Other - Last Name:MULDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:855 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7134
Mailing Address - Country:US
Mailing Address - Phone:616-395-2020
Mailing Address - Fax:616-396-8628
Practice Address - Street 1:855 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7134
Practice Address - Country:US
Practice Address - Phone:616-395-2020
Practice Address - Fax:616-396-8628
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI4901004253152W00000X
MI4901004253152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI1501001Medicare PIN